Nicklas Olsson Department of Orthopaedics, Institute of Clinical Sciences Sahlgrenska Academy at University of Gothenburg Gothenburg , Sweden 2013 ACUTE ACHILLES TENDON RUPTURE Outcome, Prediction and[.]
ACUTE ACHILLES TENDON RUPTURE Outcome, Prediction and Optimized Treatment Nicklas Olsson Nicklas Olsson Department of Orthopaedics, Institute of Clinical Sciences Sahlgrenska Academy at University of Gothenburg Gothenburg , Sweden 2013 Acute Achilles Tendon Rupture © Nicklas Olsson 2013 nicklas.olsson@gu.se ISBN 978-91-628-8633-2 Printed in Gothenburg, Sweden, 2013 by Ineko AB Cover illustration by Annette Dahlström Design by Annika Enderlein Samuelsson / A little company AB “If you can’t explain it simply, you don’t understand it well enough” Albert Einstein ACUTE ACHILLES TENDON RUPTURE Outcome, Prediction and Optimized Treatment Nicklas Olsson Department of Orthopaedics, Institute of Clinical Sciences Sahlgrenska Academy at University of Gothenburg ABSTRACT The optimal treatment for Achilles tendon rupture is the subject of debate and could be either surgical or non-surgical with various alternatives in terms of immobilization and rehabilitation The purpose of this thesis was to evaluate the short- and long-term outcome of a new surgical treatment protocol, including early tendon loading and ROM training, in comparison with non-surgical treatment using a functional brace Patients in this randomized, controlled trial were evaluated with regard to symptoms, function and complications at 3, and 12 months Predictors of outcome were assessed in a multiple linear regression model The outcome two years after injury was also evaluated in a previous randomized study of Achilles tendon rupture The studies showed no significant differences between surgical and non-surgical treatment in terms of symptoms, physical activity level or quality of life There was a trend towards a greater improvement in function in surgically treated patients No re-ruptures occurred in the group treated with the new surgical technique The heel-rise test showed that half the patients were unable to perform a single heel rise three months after injury and this ability appears to be an important early achievement, which influences patient-reported outcome and physical activity Future treatment protocols focusing on regaining strength early after injury appear to be of great importance Regardless of surgical or non-surgical treatment, there were significant functional deficits on the injured side compared with the contralateral side two years after the tendon rupture and the patients appear to adjust to these changes Treatment was a moderate predictor, in contrast to age and BMI, which were relatively strong predictors of function and symptoms respectively This thesis found that an Achilles tendon rupture impacts heavily on a person’s general health and quality of life and has a significant effect on lower leg function but with large inter-individual differences, indicating that the choice of treatment should be based on the best available evidence in combination with individual patient factors Keywords: Achilles tendon rupture, Outcome, Functional evaluation, Achilles tendon Total Rupture Score (ATRS), Predictors, Heel-rise, Rehabilitation ISBN: 978-91-628-8633-2 Nicklas Olsson Acute achilles tendon rupture SAMMANFATTNING PÅ SVENSKA Akillessenan är kroppens största sena och har relativt hög risk att skadas En akut hälseneruptur drabbar vanligen medelålders manliga motionsidrottare Allt fler skadas bland befolkningen och 1996 redovisades en incidens på 37 per 100 000 invånare och år Det finns flera olika behandlingsalternativ såsom kirurgisk och icke-kirurgisk behandling, men även olika typer av rehabilitering och immobilisering (avlastning av fotleden i gips eller i s.k ortos) Konsensus saknas om optimal behandling både på gruppnivå och för den enskilde patienten Vid val av behandling har man i litteraturen huvudsakligen vägletts utifrån risken för komplikationer framför allt reruptur Valet står då mellan kirurgiska komplikationer såsom sårinfektion, ärrproblem och nervskada och risken för reruptur som har visats vara vanligare vid icke-kirurgisk behandling I tidigare studier har relativt lite fokus lagts vid alla de patienter som inte drabbas av en komplikation vid rekommendation om behandling Syftet med avhandlingen var att vid en akut hälseneruptur utvärdera symtom och funktion tidigt och sent i läkningsprocessen, identifiera vilka faktorer som kan prediktera utfallet samt att bedöma möjligheten att optimera behandlingen med en stabil kirurgisk teknik och accelererad rehabilitering En randomiserad studie genomfördes där stabil kirurgisk teknik med accelererat rehabiliteringsprotokoll jämfördes mot behandling utan kirurgi i en belastningsbar ortos Patienterna följdes i ett år och testades med avseende på patient-rapporterade symtom, funktionsmätningar (hopp-, styrke-, och uthållighetstester och förmågan att utföra en enbent tåhävning) samt komplikationer Statistisk analys med en multipel linjär regressionsmodell utfördes för att identifiera vilka faktorer som kunde prediktera utfallet efter en hälseneruptur Efteruppföljning av patienter från en tidigare studie avseende symtom och funktion utvärderades två år efter skada Den randomiserade studien visade inga skillnader mellan behandlingsgrupperna avseende symtom, fysisk aktivitetsnivå och livskvalitet Det fanns en trend mot att den kirurgiska gruppen visade bättre resultat avseende funktion, även om det endast var statistiskt säkerställt i två typer av hopptester Ingen reruptur uppkom i den kirurgiskt behandlade gruppen, däremot uppstod reruptur hos fem patienter i den icke-kirurgiskt behandlade gruppen Tre månader efter den initiala skadan kunde cirka hälften av patienterna utföra en enbent tåhävning och de som klarade detta funktionsmått var oftare yngre, män och hade lägre grad av symtom Oavsett behandling uppvisar många patienter betydande nedsättning av funktion två år efter skada, även om många uppger låg grad av symtom Val av behandlingsprotokoll (kirurgisk eller icke-kirurgisk) är en variabel som måttligt predikterar grad av symtom och i mindre utsträckning funktion Ökande ålder är däremot en relativt stark prediktor för sämre funktion samt att högre BMI predikterar också relativt starkt för högre grad av symtom Resultaten visar att behandlingen med en stabil kirurgisk teknik och accelererat rehabiliteringsprotokoll är en säker behandlingsmetod som i studien inte gav någon reruptur Inga statistiska skillnader mellan behandlingsgrupperna avseende på symtom, fysisk aktivitet, livskvalitet kunde påvisas Patienter uppvisar däremot betydande funktionsnedsättningar två år efter skadan oavsett behandling och patienterna förefaller anpassat sig till detta Tåhävningstestet verkar vara ett viktigt mått i den tidiga rehabiliteringsfasen som påverkar utfallet Val av behandling tycks inverka relativt lite i förhållande till andra faktorer såsom ålder och BMI, därför kan denna studie vara ett tidigt steg mot ett mer vetenskapligt underbyggt val av individualiserad behandling PREFACE PERSONAL REFLECTION As a middle-aged man, I can easily identify with all the patients suffering an Achilles tendon rupture We are in a period of life where I, along with others, have high expectations of our ability to take part in physical activity I want to go on cycling, running and skiing without my body failing and I find it very difficult to accept impairments in bodily functions This thesis shows scientifically the deficits in function after an Achilles tendon rupture and, unfortunately, I have close personal experience of the impact of an Achilles tendon rupture To summarize: “That’s one small slip for a man, one giant leap for quality of mankind” Personal fear of not having the ability to move about is a strong argument and motivation for future research Nicklas Olsson Acute achilles tendon rupture LIST OF PAPERS This thesis is based on the following studies, referred to in the text by their Roman numerals I Major functional deficits persist years after acute Achilles tendon rupture Olsson N, Nilsson-Helander K, Karlsson J, Eriksson B I, Thomeé R, Faxén E, Silbernagel K G Knee Surg Sports Traumatol Arthrosc 2011; 19: 1385-93 II Ability to perform a single heel-rise is significantly related to patient-reported outcome after Achilles tendon rupture Olsson N, Karlsson J, Eriksson B I, Brorsson A, Lundberg M, Silbernagel K G Scand J Med Sci Sports; E-published, DOI-10.1111/j.1600-0838.2012.01497.x III A randomized, controlled study comparing stable surgical repair, including accelerated rehabilitation, with non-surgical treatment for acute Achilles tendon rupture Olsson N, Silbernagel K G, Eriksson B I, Sansone M, Brorsson A, Nilsson-Helander K, Karlsson J Manuscript provisionally accepted for publication in Am J Sports Med IV Predictors of clinical outcome after an acute Achilles tendon rupture Olsson N, Petzold M, Brorsson A, Karlsson J, Eriksson B I, Silbernagel K G Manuscript Contents ABBREVIATIONS 10 DEFINITIONS 11 INTRODUCTION 12 1.1 Anatomy 1.2 Structure of the tendon 1.3 Circulation 1.4 Innervation 1.5 Metabolism 1.6 Biomechanics 1.7 Epidemiology 1.8 Etiology 1.9 Mechanism of rupture 1.10 Presentation and diagnosis 1.11 Tendon healing 1.12 Stimulation of healing by mechanical load 13 15 16 16 16 16 18 18 18 19 19 20 REVIEW OF THE LITERATURE 21 2.1 Systematic review comparing surgical with non-surgical treatment 2.2 Recent randomized, controlled studies comparing surgical with non-surgical treatment 2.3 Summary of scoring systems and functional outcome measurements 2.4 Short- and long-term results after an acute Achilles tendon rupture 2.5 Weight-bearing and functional bracing after an acute Achilles tendon rupture 2.6 Different surgical techniques 2.6.1 Surgical suture technique 2.6.2 Augmented repair 2.6.3 Mini-invasive repair 2.7 Achilles tendon length 2.8 Predictor studies 21 26 28 29 30 32 32 34 35 36 37 AIMS OF THE STUDIES 39 METHODS 40 4.1 Treatment Study I 4.2 Treatment Studies II, III, IV 4.3 Primary outcome in the randomized, controlled studies 40 41 44 Functional evaluation 44 45 45 SUBJECTS 49 5.1 Ethics 52 STATISTICAL METHODS 53 SUMMARY OF PAPERS 55 7.1 Study I 7.2 Study II 7.3 Study III 7.4 4.4 Evaluation 4.5 Patient-reported outcome and physical activity 4.6 Study IV 55 56 58 64 DISCUSSION 66 8.1 Surgical or non-surgical treatment 8.2 Complications 8.3 Symptoms 8.4 Physical activity and return to sports 8.5 Fear of movement – kinesiophobia 8.6 General health 8.7 Function in the short term 8.8 Functional deficits persist 8.9 Tendon length 8.10 Adaptation 8.11 Difference in gender 8.12 Predictors 66 68 69 71 73 74 74 75 76 78 79 79 LIMITATIONS 81 10 CONCLUSIONS 83 11 FUTURE PERSPECTIVES 84 12 ACKNOWLEDGEMENTS 86 13 REFERENCES 88 14 APPENDIX 1-2 96 ABBREVIATIONS ADL Activities of Daily Life ATRS Achilles tendon Total Rupture Score BMI Body Mass Index CI Confidence Interval Drop CMJ Drop Counter Movement Jump EQ-5D™ EuroQol, a generic health-related quality of life score FAOS Foot and Ankle Outcome Score LSI Limb Symmetry Index MRI Magnetic Resonance Imaging PAS Physical Activity Scale QoL Quality of Life RCT Randomized Controlled Trial ROM Range of Motion RR Relative Risk or Risk Ratio RSA Radiostereometric Analysis SD Standard Deviation SMFA Short Musculoskeletal Function Assessment SSC Stretch Shortening Cycle TSK-SV Tampa Scale for Kinesiophobia Swedish Version US Ultrasonography VAS 10 Visual Analogue Scale Nicklas Olsson Acute achilles tendon rupture Eva Runesson, PhD, for appreciated collaboration in the randomized trial Mattias Ahldén, MD, co-worker, for always most valuable discussions and analyses and for being a great colleague Also for being a very close friend, sharing the ups and downs during the work on this thesis Ninni Sernert, associate professor, and all the members of the “Gran Canaria Research Group”, for scientific advice Kristian Samuelsson, MD, PhD, for with generosity and friendship IT support and your knowledge of research, always in the arthroscopic team, Orthopedic Department at Sahlgrenska University Hospital, Mölndal, for helping me with randomization and the treatment of the patients This thesis would not have been possible without your support All my colleagues Magnus Karlsson, MD, and Peter Nyberg, MD, present and former head of the Orthopedic Department at Sahlgrenska University Hospital, Mölndal, and all my colleagues for clinical support Leif Swärd, associate professor, co-worker, for friendship and always sharing your exper- tise and clinical advice Ulf Nordensson, MD, co-worker, for being a great friend and teaching me all about shoulder surgery All my colleagues and staff at OrthoCenter IFK-Kliniken, for your encouragement and daily support in clinical work Margareta Stärnerz, for remarkable practical support during work on this thesis, you are invaluable! Elsa Giselsson and Agneta Dubár-Karlsson for great help with the “Achilles Tendon Clinic” Linda Johanssson, research administrator, for invaluable support in all practical matters and administration Jeanette Kliger, language Annette Dahlström, for superb illustrations Annika Samuelsson, for All the participants My friends, for editor, for excellent linguistic revision of this thesis most valuable support with layout and design in this thesis, for spending time on evaluations all great things far away from research My parents, Ingrid and Håkan, for providing me with a good platform in life Finally, but most of all, my loving family, Anneli, Linn and Johan, for being the best of all Financial support was obtained from the Swedish National Center for Research in Sports (CIF) 87 13 REFERENCES Aktas S, Kocaoglu B, Nalbantoglu U, Seyhan M, Guven O End-to-end versus augmented repair in the treatment of acute Achilles tendon ruptures J Foot Ankle Surg 2007;46(5):336-340 Andersson T, Eliasson 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Beumer A Surgical treatment of achilles tendon rupture: examination of strength of types of suture techniques in a cadaver model Acta Orthop 2005;76(3):408-411 170 Zhang J, Wang JH Mechanobiological response of tendon stem cells: implications of tendon homeostasis and pathogenesis of tendinopathy J Orthop Res 2010;28(5):639-643 95 14 APPENDIX 1-2 TREATMENT PROTOCOL – achilles tendon rupture surgically treated Week 0-2: Visit orthopaedic surgeon Treatment: Walker brace with heel lifts, weight-bearing through the heel as tolerated, use of crutches Referral to orthopedic technician for shoe heel-lift (use shoe with heel-lift on the healthy side) Wearing the walker brace while sleeping for weeks Exercise program: Home exercises daily Performed while wearing the walker brace • Isometric submaximal plantar flexion (5x5 sec, once per hour) • Toe exercises, flexion-extension (3x20 repetitions, once per hour) After weeks: Treatment: Walker brace with heel lifts (take off the upper lift), full weight-bearing, use of crutches if needed Allowed to take off the walker brace for washing and airing the foot When the walker brace is removed, no weight-bearing or dorsiflexion of the foot is allowed Exercise program: Home exercises daily as described above (increase the intensity) Visit to physical therapist times per week: • • • • • • • Exercise bike wearing the walker brace Active range of motion (ROM) up to 15° plantar flexion without walker brace (the angle based on the heel-height) Active plantar flexion with yellow rubber-band (ROM as above) Sitting heel-rise – no weight-bearing (starting position from the heel-height) Gait training and balance exercises with the walker brace without crutches Squats (fitness ball behind the back) Other knee/hip-exercises with no ankle involvement After weeks: Treatment: Walker brace with heel lift (take off the upper lift), full weight-bearing Exercise program: Home exercises daily as described above (increase the intensity) Visit to physical therapist times per week: • Exercise bike wearing the walker brace • Active range of motion (ROM) up to 10° plantar flexion without walker brace • Active plantar flexion with green rubber-band (ROM as above) 96 Nicklas Olsson Acute achilles tendon rupture • • • • • Sitting heel-rise – with light weight (starting position from the heel-height) Supination- and pronation–exercises with rubber-band Gait training and balance exercises with the walker brace Squats (fitness ball behind the back) Other knee/hip-exercises with no ankle involvement After weeks: Treatment: Walker brace without heel lift, full weight-bearing Exercise program: Home exercises daily as described above (increase the intensity) Visit to physical therapist times per week: • • • • • • • • • Exercise bike wearing the walker brace Active range of motion (ROM) up to 0° plantar flexion without walker brace Active plantar flexion in a cable machine (ROM as above) Sitting heel-rise – with weight Supination- and pronation–exercises in a cable machine Gait training and balance exercises with the walker brace Squats (fitness ball behind the back) Other knee/hip-exercises with no ankle involvement Leg press After weeks: Visit orthopaedic surgeon Treatment: Wean off walker brace Use of shoes with heel-lift (bilateral) for weeks, knee- high compression socks (17-20mm Hg) to prevent swelling Exercise program: Important that all exercises are performed slowly and carefully Home exercises: • Active ankle exercises for ROM, ankle exercises (DF, PF, Sup, Pron) with rubber-band, balance exercises, sitting heel-rise, standing heel-rise (50% weight-bearing or less on the injured side), gait training Visit to physical therapist times per week: • Exercise bike • Active range of motion (ROM) • Sitting heel-rise – with weight (starting position from the shoe heel-height) • Standing heel-rise on two legs • Active plantar flexion in a cable machine (max 0° plantar flexion) • Heel-rise in leg press (max 0° plantar flexion) • Supination- and pronation – exercises in a cable machine • Gait training • Balance exercises • Squats • Step (walk slowly) • Other knee/hip-exercises with no ankle involvement 97 After weeks: Treatment: Use of shoes with heel-lift until 10 weeks after surgery, knee-high compression socks (17-20mm Hg) to prevent swelling Exercise program: Important that all exercises are performed slowly and carefully Home exercises: As described above and walking 20 per day Visit to physical therapist times per week: • • • • • • • As described above, increase the intensity Sitting heel-rise – with weight (increase the load) Standing heel-rise on two legs - transcend gradually to one leg Active plantar flexion, supination and pronation in a cable machine Heel-rise in leg press Cable machine standing leg lifts Balance exercises (wobble-board, balance pods - weight bearing in the middle of the foot) Evaluation at research lab Treatment: Use of regular shoes after 10 weeks, barefoot after 12 weeks, knee-high compression socks (17-20mm Hg) to prevent swelling Exercise program: Important to gradually increase the load considering the patient´s status Home exercise: Walking 20 per day After 12 weeks: Visit to physical therapist times per week: • • • • • Intensify the exercises by increasing load (as before) Increase the load gradually from two leg standing heel-rises to one leg standing heel-rises both concentrically and eccentrically Quick rebounding heel-rises (start with two legs) Start with gentle jog (thick mattress, in 8´s, zig-zag) Start with two-legged jumps and increase gradually After 14 weeks: Evaluation at research lab and 12 months after surgery, visit orthopaedic surgeon months • Running outdoors, if the patient has a good technique • Group training (similar to aerobics, adapted for knee-injured patients) • Return to sports earliest after 16 weeks (non-contact sports) and 20 weeks (contact sports) • Possibility for the patient to be evaluated at the research lab before months if needed to estimate the ability to return to sports 98 Nicklas Olsson Acute achilles tendon rupture TREATMENT PROTOCOL – achilles tendon rupture non-surgically treated Week 0: Treatment: Walker brace with heel lifts, weight-bearing through the heel as tolerated, use of crutches Referral to orthopedic technician for shoe heel-lift (use shoe with heel-lift on the healthy side) Walker brace: Allowed to take off the walker brace for washing and airing the foot When the walker brace is removed, no weight-bearing or dorsiflexion of the foot is allowed Walker brace is to be worn while sleeping Exercise program: Home exercises daily wearing the walker brace – move the toes several times a day After weeks: Treatment: Walker brace with heel lifts (take off the upper lift), full weight-bearing, use of crutches if needed Exercise program: Home exercises as described above After weeks: Treatment: Walker Exercise program: brace with heel lift, full weight-bearing Home exercises daily as described above After weeks: Treatment: Walker Exercise program: brace without heel lift full weight-bearing Home exercises daily as described above After weeks: Visit orthopaedic surgeon Treatment: Wean off walker brace Use of shoes with heel-lift (until 14 weeks after injury), knee-high compression socks (17-20mm Hg) to prevent swelling Exercise program: Important that all exercises are performed slowly and carefully Home exercises: • Active ankle exercises for ROM, ankle exercises (DF, PF, Sup, Pron) with rubber-band, balance exercises, sitting heel-rise, standing heel-rise (50% weight-bearing or less on the injured side), gait training Visit to physical therapist times per week: • • • • Exercise bike Active range of motion (ROM) Sitting heel-rise – with weight (starting position from the shoe heel-height) Standing heel-rise on two legs 99 • • • • • • Active plantar flexion with a rubber-band (max 0° plantar flexion) Supination- and pronation – exercises with a rubber-band Gait training Balance exercises (not wobble boards or balance pods) Squats (fitness ball behind the back) Other knee/hip-exercises with no ankle involvement After 10 weeks: Use of shoes with heel-lift until 14 weeks after injury, knee-high compression socks (17-20mm Hg) to prevent swelling Exercise program: Important that all exercises are performed slowly and carefully Home exercises: As described above Treatment: Visit to physical therapist times per week: • • • • • • • • As described above, increase the intensity Sitting heel-rise – with weight (starting position from the shoe heel-height) Standing heel-rise on two legs - progress gradually to one leg Active plantar flexion, supination and pronation in a cable machine Heel-rise in leg press Balance exercises (wobble-board, balance pods-weight bearing in the middle of the foot) Step (walk slowly) Cable machine standing leg lifts Evaluation at the research lab Treatment: Use of shoes with heel-lift until 14 weeks after injury, knee-high compression socks (17-20mm Hg) to prevent swelling Exercise program: Important that all exercises are performed slowly and carefully Home exercises: As described above and walking 20 per day After 12 weeks: Visit to physical therapist times per week: • As described above, increase the intensity After 16 weeks: Treatment: Use of regular shoes after 14 weeks, barefoot after 16 weeks, knee-high compression socks (17-20mm Hg) to prevent swelling Exercise program: Important to gradually increase the load considering the patient´s status Home exercise: Walking 20 per day Visit to physical therapist times per week: • • • 100 Intensify the exercises by increasing the load (as before) Increase the load gradually from two leg standing heel-rises to one leg standing heel-rises both concentrically and eccentrically Start with gentle jog (thick mattress, in 8´s, zig-zag) Nicklas Olsson Acute achilles tendon rupture • Start with two-legged jumps and increase gradually Evaluation at the research lab and 12 months after injury, visit orthopaedic surgeon months • Running outdoors, if the patient has a good technique • Group training (similar to aerobics, adapted for knee-injured patients) • Return to sports earliest after 20 weeks (non-contact sports) and 24 weeks (contact sports) • Possibility for the patient to be evaluated at Lundberg Lab before months if needed to estimate the ability to return to sports After 18 weeks: 101